Kidney Transplant Surgery

Introduction

If you or a family member is being considered for a kidney transplant, it usually means that kidney function has fallen to a very low level — the stage doctors call kidney failure or end-stage kidney disease. At this point, the body can no longer filter waste, balance fluids, and control blood pressure on its own. Dialysis can take over some of this work, but a successful kidney transplant restores far more of normal kidney function and, for most eligible patients, offers a longer life with fewer restrictions.

A kidney transplant is a major operation, and the decisions around it — donor type, timing, evaluation, the surgery itself, and lifelong follow-up — can feel overwhelming. This guide walks through the full journey: what the surgery involves, who is considered a candidate, what alternatives exist, how donors are evaluated, what happens in the operating room and the hospital, and what life looks like in the months and years after transplant.

The article is written for adults with kidney failure who are already in the transplant pathway, for family members considering donation, and for parents of children who need a transplant. It is informational and is meant to support, not replace, the conversations you will have with your transplant team.

What Is Kidney Transplant Surgery?

A kidney transplant is an operation in which a healthy kidney from another person — the donor — is placed into the body of a person whose own kidneys have failed. The transplanted kidney is called the graft. Once blood flow is restored, the new kidney takes over the work that the failed kidneys can no longer do: filtering waste from the blood, removing extra fluid as urine, balancing salts and minerals, helping to control blood pressure, and producing hormones that support red blood cell production and bone health.

One feature of kidney transplant surgery often surprises patients: in most cases, the failed kidneys are not removed. They are usually left in place because removing them adds risk without adding benefit. The new kidney is placed lower down, in the front part of the pelvis (the iliac fossa), where it is easier to connect to the large blood vessels of the leg and to the bladder.

A kidney transplant is not a cure for chronic kidney disease, and it does not erase the original illness that led to kidney failure. It replaces lost kidney function. To protect the new kidney from being attacked by the body’s immune system, lifelong medications called immunosuppressants are required.

Why Is Kidney Transplant Surgery Performed?

Kidney transplant surgery is performed when kidney function has dropped to a level at which the body can no longer maintain health without help — either dialysis or a transplant. Doctors usually start serious transplant conversations when the estimated glomerular filtration rate (eGFR), a measure of kidney function, falls below about 20 mL/min/1.73 m², or earlier if function is declining quickly.

Common underlying causes of kidney failure that lead to transplantation include:

• Diabetes (the most common cause worldwide)
• Long-standing high blood pressure (hypertension)
• Glomerulonephritis — inflammation of the kidney’s filtering units
• Polycystic kidney disease, an inherited condition in which cysts replace normal kidney tissue
• Lupus and other autoimmune diseases affecting the kidneys
• Recurrent or severe kidney infections, reflux disease, and obstructive uropathy
• Congenital kidney and urinary tract problems (an important cause in children)
• Unknown causes — in some patients no specific diagnosis is ever confirmed

Major guidelines, including those from KDIGO (Kidney Disease: Improving Global Outcomes), describe kidney transplantation as the preferred long-term treatment for most eligible patients with kidney failure, because it is associated with longer survival and better quality of life compared with staying on long-term dialysis.

Who Is a Candidate for Kidney Transplant?

Not everyone with kidney failure is a candidate for transplantation. The transplant team evaluates whether the operation and lifelong immunosuppression are likely to do more good than harm. The assessment looks at the heart, lungs, blood vessels, infections, cancers, mental health, social support, and the ability to take medications reliably.

Factors that generally support being a candidate include:

• Kidney failure that is permanent and not expected to recover
• Overall fitness to undergo surgery and anaesthesia
• No active untreated infection
• No active cancer (or a defined waiting period after successful cancer treatment, as advised by oncology)
• A reasonable likelihood of taking immunosuppressant medication every day, for life
• Adequate family or community support

Conditions that may delay or prevent transplantation include severe heart disease that cannot be treated, active cancer, active substance misuse, severe untreated psychiatric illness, or other illnesses that significantly shorten life expectancy independent of kidney function. Older age is not, by itself, a reason to refuse a transplant; many adults in their sixties and seventies receive transplants when overall health is good.

In some patients, transplant can be performed before dialysis is ever started — this is called a pre-emptive transplant. Studies suggest that pre-emptive transplantation, especially from a living donor, is associated with some of the best long-term outcomes.

Alternatives to Kidney Transplant

For people with kidney failure, the main alternatives to transplantation are dialysis and, in some situations, conservative kidney care. Each has a different role.

Haemodialysis

Haemodialysis filters blood through an external machine, usually three times a week, with each session lasting around four hours. It is most often done in a dialysis centre, although some patients are trained to do it at home. Access for haemodialysis is created surgically, most commonly as an arteriovenous (AV) fistula in the arm.

Peritoneal Dialysis

Peritoneal dialysis uses the lining of the abdomen (the peritoneum) as a natural filter. A catheter placed in the abdomen allows dialysis fluid to enter and drain. It is typically done at home, either by manual exchanges through the day or overnight with a machine.

Conservative Kidney Care

For some patients — usually older adults with multiple serious illnesses — neither dialysis nor transplant offers a clear benefit. Conservative kidney care focuses on managing symptoms, slowing further decline where possible, and supporting quality of life without dialysis. This is a clinical decision made carefully with the patient, family, and nephrologist.

Why Transplant Is Often Preferred

For patients who are eligible, transplantation is generally associated with longer life, more energy, fewer dietary and fluid restrictions, greater freedom to travel and work, and better fertility in younger adults. Dialysis, by contrast, replaces only part of kidney function and demands a fixed weekly schedule. The trade-off with transplant is the need for surgery, lifelong immunosuppression, and acceptance of the risks that come with it.

Types of Donors

Kidney transplants can come from a living donor or a deceased donor. The donor type significantly affects how the transplant is planned and, on average, how long the new kidney lasts.

Living Related Donor

A living related donor is a close family member — parent, sibling, child, or, depending on country regulations, certain other near relatives. Genetic similarity often improves tissue matching, and living donor kidneys tend to function immediately and last longer than deceased donor kidneys on average.

Living Unrelated Donor

A living unrelated donor is most often a spouse or, in some cases, a close friend. In India, donation from an unrelated person requires approval by a hospital-based authorisation committee under the Transplantation of Human Organs and Tissues Act (THOTA), which is designed to confirm that donation is voluntary and not based on payment. Commercial organ donation is illegal in India.

Deceased Donor

A deceased donor kidney comes from a person who has died, usually after brain death has been declared, and whose family has consented to organ donation. Patients waiting for a deceased donor kidney are placed on a waiting list. Waiting times vary considerably depending on blood group, antibody profile, and local organ availability.

Paired Kidney Exchange

ABO-Incompatible and Sensitised Transplants

In selected centres, transplants can also be performed across blood-group mismatches or in patients with high levels of pre-formed antibodies, using extra treatments before and after surgery to lower the risk of rejection. These are more complex transplants and are considered when no easier option is available.

Pre-Transplant Evaluation

Before a transplant is scheduled, both the recipient and any living donor go through a detailed evaluation. This usually takes weeks to months and involves a team of nephrologists, transplant surgeons, transplant coordinators, and other specialists.

Recipient Evaluation

For the person who will receive the kidney, the evaluation typically includes:

• Blood group testing and HLA (human leukocyte antigen) typing
• Antibody screening to look for substances that could attack the new kidney
• Crossmatch testing once a possible donor is identified
• Detailed kidney function and urine tests
• Heart assessment, often including an ECG, echocardiogram, and sometimes a stress test or coronary angiogram
• Chest X-ray and lung assessment
• Screening for infections such as hepatitis B, hepatitis C, HIV, tuberculosis, and others depending on local risk
• Age-appropriate cancer screening
• Dental review to address any sources of infection
• Psychological and social assessment, including support at home and ability to take medications regularly

Donor Evaluation

For a living donor, the evaluation is at least as careful as the recipient’s. The aim is to confirm that donating a kidney is safe for the donor in both the short and long term. Tests usually include:

• Blood group and tissue typing
• Detailed kidney function tests and 24-hour urine collection
• Imaging of the kidneys and their blood vessels (CT or MR angiography)
• Screening for diabetes, high blood pressure, heart disease, and infections
• Cancer screening as appropriate
• Independent psychological assessment to confirm donation is voluntary

KDIGO living-donor guidelines emphasise that donor wellbeing is the priority of the donor workup, separate from the recipient’s interests. A potential donor can withdraw at any stage without giving a reason.

Regulatory Approval in India

In India, the Transplantation of Human Organs and Tissues Act (THOTA) defines who can donate. Donation from a “near relative” (parent, child, sibling, spouse, grandparent, or grandchild) is allowed after standard hospital approval. Donation from an unrelated person requires additional clearance from a hospital-based authorisation committee, which confirms the donation is altruistic. Deceased donation is coordinated through NOTTO and state-level networks.

Preparing for Kidney Transplant Surgery

Once evaluation is complete and a donor is confirmed (or a deceased donor offer is accepted), preparation focuses on getting both the recipient and donor into the best possible condition for surgery.

Typical preparation steps include:

• Optimising blood pressure, blood sugar, and fluid status
• Adjusting or stopping certain medications, including blood thinners, as directed
• Updating vaccinations — live vaccines are usually avoided after transplant, so any catch-up is done beforehand
• Treating any active infection or dental issue
• Confirming the most recent dialysis session before surgery in dialysis-dependent patients
• Final crossmatch test shortly before surgery
• Fasting for several hours before anaesthesia

The transplant coordinator usually provides a checklist and explains when to arrive at the hospital, what to bring, and what medications to take or hold on the morning of surgery.

Surgical Approaches

Kidney transplant surgery refers to both the operation on the donor (to remove the kidney) and the operation on the recipient (to place the kidney). Different approaches exist for each.

Open Kidney Transplant (Recipient Surgery)

The standard recipient operation is performed through an open incision in the lower abdomen, usually on the right side (sometimes on the left). The surgeon connects the donor kidney’s artery and vein to the recipient’s iliac artery and vein, then joins the donor ureter to the recipient’s bladder. This approach has been used for decades and remains the most widely practised technique worldwide.

Robotic-Assisted Kidney Transplant

In some specialised centres, the recipient operation can be performed using a robotic-assisted minimally invasive approach. Smaller incisions are used, with the kidney placed through one of them. Possible benefits include less pain, lower wound infection risk, and a quicker return to activity. Robotic transplantation is not available everywhere and is typically offered to selected patients.

Laparoscopic Donor Nephrectomy (Donor Surgery)

For living donors, the kidney is most often removed by laparoscopic surgery, sometimes with robotic assistance. Several small incisions allow surgeons to free the kidney inside the body, with one slightly larger incision used to lift it out. Compared with traditional open donor surgery, this approach is associated with less pain, shorter hospital stay, smaller scars, and a faster return to work for the donor.

Open Donor Nephrectomy

Open donor surgery, through a flank or abdominal incision, is still used in some situations — for example, where laparoscopic surgery is not available or where the donor’s anatomy makes a minimally invasive approach difficult.

What Happens During Kidney Transplant Surgery

On the day of surgery, the recipient is admitted to the transplant unit, final blood tests and the crossmatch result are confirmed, and any last-minute dialysis is given if needed. Pre-operative medications — including the first doses of immunosuppressant drugs and antibiotics — are usually started before going to the operating room.

Inside the operating room, the recipient receives general anaesthesia, so they are fully asleep and feel nothing. A urinary catheter is placed. The surgeon makes a curved incision in the lower abdomen. The donor kidney, which has been carefully prepared on a back table, is brought into the field. Its artery is sewn to one of the iliac arteries, its vein to an iliac vein, and the donor ureter is connected to the bladder, sometimes with a small temporary stent inside the ureter to protect the join while it heals.

Once the connections are checked and blood flow is restored, the new kidney often turns pink quickly and may begin producing urine within minutes. The surgical team then places drains as needed and closes the wound. The whole operation typically takes three to four hours.

For the living donor, the kidney is removed in a separate operating room, often at the same time. The donor recovers in a separate area of the hospital, and the two operations are timed so that the kidney is out of the body for as short a period as possible.

Recovery and Healing

The First Days in Hospital

After surgery, patients usually spend the first day or two in an intensive care or high-dependency unit so that blood pressure, urine output, fluid balance, and kidney function can be monitored closely. The new kidney’s function is followed by blood tests and ultrasound scans. The urinary catheter usually stays in for several days. A small drain near the wound may be left for a short time.

In many living-donor transplants, the new kidney works almost immediately, and dialysis is no longer needed. In some patients — more often with deceased-donor kidneys — the kidney is slow to wake up, a situation called delayed graft function. Dialysis may be needed for a short time until the kidney recovers.

Hospital Stay

A typical hospital stay after kidney transplant is around 7 to 14 days, though this varies between centres and patients. During this time, the team teaches the patient about immunosuppressant medications, signs of rejection and infection, wound care, and follow-up plans.

The First Few Weeks at Home

After discharge, follow-up visits are very frequent at first — often two or three times a week — with blood tests at each visit to track kidney function and medication levels. Patients are usually advised to:

• Walk regularly but avoid heavy lifting and strenuous activity
• Keep the wound clean and dry
• Drink fluids as advised by the team
• Take medications at the same times every day
• Watch for fever, reduced urine output, pain over the new kidney, or sudden weight gain, and report these immediately

Returning to Normal Activity

Most patients are able to resume light daily activities within a few weeks and gradually return to work and exercise over 6 to 12 weeks, depending on the type of work and how recovery is going. Heavy lifting, contact sports, and strenuous abdominal exercises are generally avoided for several months.

For living donors, recovery is usually quicker. Most donors are home within a few days and back to most normal activities within 4 to 6 weeks, with full recovery over a few months. Long-term follow-up of donors is recommended to monitor kidney function and blood pressure.

Immunosuppression: Protecting the New Kidney

The immune system normally attacks anything it sees as “foreign,” including a transplanted kidney. Immunosuppressant medications calm the immune system enough to protect the graft while still leaving the body able to fight most infections.

Most transplant programmes use a combination of medications, typically including:

• A calcineurin inhibitor such as tacrolimus or cyclosporine
• An antiproliferative agent such as mycophenolate
• A corticosteroid such as prednisolone, in lower doses over time

An “induction” agent may also be given around the time of surgery to lower the early risk of rejection. Specific drug choices are decided by the transplant team based on the patient’s risk profile.

Risks and Complications

Kidney transplant is a well-established operation, but it carries real risks. Understanding them helps patients and families recognise problems early.

Surgical Risks

• Bleeding during or after surgery
• Blood clots in the new kidney’s artery or vein
• Urine leak from the connection between the ureter and bladder
• Narrowing of the ureter over time, sometimes needing a stent or further surgery
• Wound infection or hernia at the incision site
• Lymphocele — a collection of lymph fluid near the new kidney that occasionally needs drainage

Rejection

Rejection happens when the immune system attacks the new kidney. It can occur within days (acute rejection) or over years (chronic rejection). Many episodes of acute rejection can be reversed with medication if caught early, which is why blood tests are so frequent in the first months. Warning signs may include reduced urine output, swelling, fever, tenderness over the new kidney, or rising creatinine on blood tests.

Infection

Because immunosuppression weakens the body’s defences, infections are more common after transplant. These can be bacterial, viral (such as cytomegalovirus and BK virus), or fungal. Most centres use preventive antibiotics and antiviral medications for several months after transplant.

Medication Side Effects

Long-term immunosuppression can contribute to high blood pressure, diabetes, raised cholesterol, weight gain, tremor, gum changes, increased risk of certain cancers (especially skin cancer), and bone thinning. Regular monitoring helps detect and manage these.

Recurrence of the Original Disease

Some kidney diseases — certain types of glomerulonephritis, for example — can come back in the transplanted kidney over time. The transplant team will discuss whether this is a particular concern.

Delayed Graft Function

Some transplanted kidneys take days or weeks to start working fully, especially deceased-donor kidneys that were outside the body for longer. Short-term dialysis may be needed during this period.

Success Rates and Long-Term Outlook

Kidney transplant outcomes have improved substantially over the past decades. While exact numbers vary between centres and depend on donor and recipient factors, the broad patterns are:

• One-year survival of patients and transplanted kidneys is generally high, often above 90 percent in well-matched living-donor transplants.
• Living-donor kidneys, on average, function for longer than deceased-donor kidneys.
• Many transplants continue to function well for 10, 15, or 20 years, and some longer; eventually, most transplants will lose function over time, and a second transplant or return to dialysis may be needed.
• Patients with controlled blood pressure, good diabetes management, and consistent medication use tend to have the best long-term outcomes.

Personalised estimates of expected outcome should come from the transplant team, who can take into account age, donor type, matching, antibody levels, and other individual factors.

Life After Kidney Transplant

For most patients, life after a successful kidney transplant is significantly closer to normal than life on dialysis. Energy returns, fluid restrictions ease, and the schedule is no longer built around dialysis sessions. At the same time, transplant brings its own routines.

Medications and Follow-up

Daily immunosuppressant medications are central to life after transplant. Other medications often include blood pressure tablets, drugs to prevent infection in the early period, statins, and others as needed. Follow-up visits are frequent in the first year and then gradually spread out, but lifelong follow-up is the standard.

Diet and Lifestyle

Many of the strict dietary restrictions of dialysis can be relaxed, but a heart-healthy, balanced diet remains important. General advice often includes:

• Plenty of fluids unless told otherwise
• Limited salt to help control blood pressure
• Balanced protein intake
• Care with food hygiene to reduce infection risk — avoiding undercooked meat, unpasteurised dairy, and unwashed raw produce
• Avoiding grapefruit and grapefruit juice, which can interfere with some immunosuppressant medications
• No smoking; alcohol only in moderation, after checking with the team

Regular physical activity, weight control, sun protection (because of higher skin cancer risk), and routine dental and eye care all matter. Vaccinations are kept up to date, but live vaccines are generally avoided.

Work, Travel, and Relationships

Most people return to work within a few months. Travel is possible, with planning — carrying medications, vaccination records, and contact details for the transplant team. Sexual function often improves after transplant, and fertility may return. Pregnancy after transplant is possible for many women but needs to be planned carefully with both the transplant team and a high-risk obstetrics team, usually waiting at least a year after transplant when kidney function is stable.

Emotional Wellbeing

The emotional side of transplant is real. Patients may feel relief, gratitude, anxiety about rejection, or guilt about the donor — sometimes all at once. Living donors, too, can have complex feelings before and after donation. Mental health support is an important part of transplant care.

Long-Term Monitoring

Lifelong monitoring is essential to protect the transplanted kidney and the patient’s overall health. Typical long-term checks include:

• Regular blood tests for kidney function (creatinine, eGFR) and drug levels
• Urine tests for protein and infection
• Blood pressure monitoring
• Diabetes and cholesterol checks
• Annual skin checks and other age-appropriate cancer screening
• Bone health checks where relevant
• Periodic ultrasound of the transplanted kidney

Some changes in kidney function are picked up only on blood tests, before any symptoms appear — which is why regular attendance is important even when patients feel well.

Kidney Transplant in Children

Children can and do receive kidney transplants, and outcomes in well-selected paediatric patients are generally good. The principles are similar to adults, but several aspects are specific to children.

In children, the most common causes of kidney failure are congenital problems of the kidneys and urinary tract, inherited kidney diseases, and certain glomerulonephritides — rather than diabetes and hypertension as in adults. Some children come to transplant having been on dialysis; others have a pre-emptive transplant before dialysis is needed.

Key differences in paediatric kidney transplant include:

• Living donors are often a parent or close relative, with the adult kidney placed in the child’s abdomen, sometimes higher up if the child is very small
• Surgery is performed by paediatric urology and transplant teams in specialised centres
• Particular attention is given to growth, nutrition, school, and development — transplant often allows children to grow more normally compared with long-term dialysis
• Immunosuppressant doses are adjusted for size and age, with close monitoring
• Adolescents need extra support during the transition from paediatric to adult transplant care, when missed medications and missed visits can put the kidney at risk

Parents and caregivers play a central role in helping younger children take medications correctly and recognise warning signs. Many transplant programmes offer family education, play therapy, and school liaison support.

Frequently Asked Questions

Is a kidney transplant better than staying on dialysis?

For most eligible patients, major guidelines describe transplantation as the preferred long-term treatment for kidney failure, with longer survival and better quality of life on average than long-term dialysis. Whether transplant is the right choice for a particular person is a clinical decision based on overall health and personal circumstances.

How long does a transplanted kidney last?

This varies. Many transplants work well for 10 to 20 years, sometimes longer, and living-donor kidneys tend to last longer than deceased-donor kidneys on average. Some kidneys are lost earlier due to rejection, recurrence of disease, or other problems. Personalised estimates should come from the transplant team.

Will I need dialysis again after a transplant?

Some patients need short-term dialysis right after transplant if the new kidney is slow to start (delayed graft function). Most patients then come off dialysis. Over many years, if the transplant eventually loses function, dialysis or a second transplant may be needed.

Can I stop my immunosuppressant medications if I feel well?

No. Immunosuppressant medications are needed for as long as the transplant works. Stopping or skipping doses, even when feeling well, is one of the main causes of rejection and graft loss. Any concerns about side effects should be discussed with the transplant team, not managed by stopping the medication.

Is donating a kidney safe for the donor?

Living kidney donation has been studied extensively. For carefully selected and evaluated donors, the short-term risks of surgery are low and most donors live healthy lives with one kidney. KDIGO living-donor guidelines outline how donor evaluation should protect long-term donor health. Donors continue to need regular follow-up to monitor kidney function and blood pressure.

Can I have children after a kidney transplant?

Many people regain fertility after transplant. Pregnancy is possible for many women with a transplant but needs to be planned with the transplant team and a high-risk obstetrics team, usually after at least a year of stable kidney function and on a pregnancy-safe medication regimen.

What signs should I report urgently after transplant?

Common warning signs include fever, decreased urine output, sudden weight gain or swelling, pain or tenderness over the transplanted kidney, persistent vomiting, severe diarrhoea, or any symptom that feels significant. When in doubt, contact the transplant team rather than waiting.

Can I travel after a transplant?

Most patients can travel, including internationally, once they are stable — usually several months after surgery. Planning ahead with the transplant team is important: medications, vaccinations, food and water safety, and access to medical care at the destination all need to be considered.

Conclusion

Kidney transplant surgery is one of the most established life-changing operations in modern medicine. For many people with kidney failure, it offers a return to a fuller, more flexible life than long-term dialysis can provide. At the same time, it is a major undertaking that brings lifelong responsibilities — careful medication use, regular follow-up, attention to infections, and ongoing partnership with a transplant team.

Understanding what is involved — from the kinds of donors, through evaluation and surgery, to recovery and long-term care — can make the journey less daunting. The most useful next step for any patient or family considering transplant is a detailed conversation with a nephrologist and a transplant centre, where individual circumstances can be reviewed in depth.